Characteristics, Prevention, and Management of Cardiovascular Disease in People Living With HIV: A Scientific Statement From the American Heart Association
Download the PDF here
Download the PDF here
Special Issue in the journal Circulation on HIV & Cardiovascular Disease, and Aging/HIV, 2 pdfs attached & below 2 press releases from the AHA.
Matthew J. Feinstein , Priscilla Y. Hsue, Laura A. Benjamin, Gerald S. Bloomfield, Judith S. Currier, Matthew S. Freiberg, Steven K. Grinspoon, Jules Levin, Chris T. Longenecker, Wendy S. Post, and On behalf of the American Heart Association Prevention Science Committee of the Council on Epidemiology and Prevention and Council on Cardiovascular and Stroke Nursing; Council on Clinical Cardiology; and Stroke Council
As early and effective antiretroviral therapy has become more widespread, HIV has transitioned from a progressive, fatal disease to a chronic, manageable disease marked by elevated risk of chronic comorbid diseases, including cardiovascular diseases (CVDs). Rates of myocardial infarction, heart failure, stroke, and other CVD manifestations, including pulmonary hypertension and sudden cardiac death, are significantly higher for people living with HIV than for uninfected control subjects, even in the setting of HIV viral suppression with effective antiretroviral therapy. These elevated risks generally persist after demographic and clinical risk factors are accounted for and may be partly attributed to chronic inflammation and immune dysregulation. Data on long-term CVD outcomes in HIV are limited by the relatively recent epidemiological transition of HIV to a chronic disease. Therefore, our understanding of CVD pathogenesis, prevention, and treatment in HIV relies on large observational studies, randomized controlled trials of HIV therapies that are underpowered to detect CVD end points, and small interventional studies examining surrogate CVD end points. The purpose of this document is to provide a thorough review of the existing evidence on HIV-associated CVD, in particular atherosclerotic CVD (including myocardial infarction and stroke) and heart failure, as well as pragmatic recommendations on how to approach CVD prevention and treatment in HIV in the absence of large-scale randomized controlled trial data. This statement is intended for clinicians caring for people with HIV, individuals living with HIV, and clinical and translational researchers interested in HIV-associated CVD.
People living with HIV face premature heart disease and barriers to care
American Heart Association Scientific Statement
Published: June 3, 2019
• People living with HIV face a higher risk of developing diseases of the heart and blood vessels compared to people without the disease.;
• Seventy-five percent of people living with HIV are over age 45 and face significant health challenges at earlier ages than people who don't have HIV.
Embargoed until 4 a.m. CT / 5 a.m. ET Mon., June 3, 2019
DALLAS, June 3, 2019 - Effective antiretroviral therapy has changed the human immunodeficiency virus (HIV) from a progressive, fatal disease to a chronic, manageable condition that is associated with higher rates of heart attacks, strokes, heart failure, sudden cardiac deaths, and other diseases compared to people without HIV, according to a new scientific statement from the American Heart Association published in the Association journal Circulation.
People living with HIV are at increased risk of heart and blood vessel diseases because of interactions between traditional risk factors, such as diet, lifestyle and tobacco use, and HIV-specific risk factors, such as a chronically activated immune system and inflammation characteristic of chronic HIV.
Tobacco use, a major risk factor for cardiovascular diseases, is common among people living with HIV. In a nationally representative U.S. sample, 42% of people living with HIV were current smokers. Heavy alcohol use, substance abuse, mood and anxiety disorders, low levels of physical activity and poor cardiorespiratory fitness are also common among people living with HIV and may contribute to elevated risk for diseases of the heart and blood vessels, according to the statement.
"Considerable gaps exist in our knowledge about HIV-associated diseases of the heart and blood vessels, in part because HIV's transition from a fatal disease to a chronic condition is relatively recent, so long-term data on heart disease risks are limited," said Matthew J. Feinstein, M.D., M.Sc., chair of the writing group for the statement and assistant professor of medicine and preventive medicine at the Feinberg School of Medicine, Northwestern University in Chicago, Illinois.
In addition, people living with HIV are often stigmatized and face significant barriers to optimal health care, such as education level, where they live, healthcare literacy, disenfranchisement from the healthcare system, cognitive impairment, injection drug use, internalized and anticipated stigma, gait and mobility impairment, frailty, depression and social isolation. There are also disparities in care based on age, race, ethnicity and gender.
Another area of concern is the aging population of people living with HIV – 75% of people living with HIV are over age 45. "Aging with HIV differs greatly from the aging issues facing the general population," said Jules Levin, M.S., in an accompanying patient perspective. Levin has been living with HIV for 35 years and is the founder and executive director of the National AIDS Treatment Advocacy Project.
"On average, people living with HIV who are over 60 years old have 3-7 medical conditions, including heart attacks, strokes, heart failure, kidney disease, frailty and bone diseases and many take 12-15 medications daily. As they age, people living with HIV are often alone and disabled, emotionally homebound due to depression, and are socially isolated. In addition, they often suffer from lack of mobility and an impaired ability to perform normal daily functions. We urgently need better awareness and more patient-focused research and care efforts for this vulnerable population," said Levin.
Providing scientifically based recommendations on how to reduce the risk of cardiovascular disease among people living with HIV is also challenging. "There is a dearth of large-scale clinical trial data on how to prevent and treat cardiovascular diseases in people living with HIV.
This is an area of research that is needed for informed decision-making and effective CVD prevention and treatment in the aging population of people living with HIV," said writing group chair Feinstein.
To assess a person living with HIV's cardiovascular risk, the statement advises a nuanced approach. This approach includes quantifying traditional heart disease risk factor burden using tools such as American Heart Association/American College of Cardiology Atherosclerotic Disease Risk Calculator, which estimates a person's ten-year risk of having a heart attack, stroke or other cardiovascular condition, as a starting point. However, the authors caution that people living with HIV may have a higher risk than indicated by the calculator. Additional considerations that should be factored into the heart disease risk assessment include family history of heart disease and HIV-specific factors, such as whether or not a patient started antiretroviral therapy soon after diagnosis.
To keep people living with HIV healthy, Feinstein emphasizes the importance of a healthy lifestyle that includes smoking cessation, adequate physical activity, eliminating or reducing the amount of alcohol consumed and a healthy diet. In addition, medications such as statin drugs, which lower cholesterol, and other medications that make blood less likely to form clots may be helpful, although more clinical trial data are needed.
Co-authors: Priscilla Y. Hsue, M.D., vice chair; Laura Benjamin, Ph.D.; Gerald S. Bloomfield, M.D., MPH; Judith S. Currier, M.D.; Matthew S. Freiberg, M.D., M.Sc.; Steven K. Grinspoon, M.D.; Jules Levin, M.S.; Chris T. Longenecker, M.D.; and Wendy S. Post. M.D., M.S.
• After June 3, view the manuscript and patient perspective online.
Published: June 3, 2019
As HIV patients live longer, heart disease might be their next challenge
By American Heart Association News
Medical therapy has transformed HIV from a terminal illness into a chronic, manageable condition. But as people with HIV live longer, they also find themselves at higher risk for heart attack, stroke and other types of cardiovascular disease.
A new American Heart Association report hopes to raise awareness about that connection, along with pointing out cardiovascular disease prevention and treatment strategies for an emerging population with unique concerns researchers have only begun to explore.
"The fact that people with HIV are living long enough to have chronic, aging-related diseases like heart disease reflects the effectiveness of contemporary HIV therapy. Life expectancy has gotten much longer than it used to be," said Dr. Matthew Feinstein, a cardiologist and chairman of the committee that wrote the scientific statement published Monday in the AHA journal Circulation.
"People are getting treated earlier and earlier and not developing immune compromise and/or AIDS-related complications, which is all good," he said. "But the downside is we're seeing earlier onset and higher relative risks for different chronic diseases among people with HIV."
Heart disease tops the concerns.
The risk of heart disease and stroke for people who have HIV is about 1.5 to two times greater than for people not infected with the virus. HIV-related cardiovascular disease accounts for 2.6 million years of healthy life lost around the world each year. That's expected to increase as an aging population of people with HIV develop risks for ailments and diseases other than AIDS.
Researchers initially thought heightened risk for cardiovascular disease among people with HIV was partially linked to antiretroviral therapy, a treatment that uses a combination of medications to suppress HIV-related infections.
But recent studies knocked down that theory after finding that people who received continuous antiretroviral therapy had lower risks of having cardiovascular events than people who went on antiretroviral therapy intermittently.
Researchers now believe the elevated heart disease risk may be related to chronic inflammation and an unusual stimulation of the immune system, triggered by HIV even when the virus is well-controlled.
"The immune system responds to any infection. In a chronic viral infection like HIV, it's thought that in the course of keeping HIV under control, there could be some off-target effects," said Dr. Judith Currier, a member of the statement's writing committee.
"In other words, the immune system is activated to control HIV and in the process of that activation, it could be increasing the risk for heart disease," said Currier, chief of the infectious diseases division at the University of California, Los Angeles's David Geffen School of Medicine.
Chronic inflammation is linked to the buildup of fatty plaque in the arteries, a risk factor for heart disease.
Risk factors, particularly smoking and high blood pressure, also play a role in elevating the chances for cardiovascular disease. But even after adjusting for those traditional risks, people with HIV still have significantly higher heart disease risks than people who don't have the virus.
Part of the frustration for doctors is a dearth of research, said Feinstein, an assistant professor of medicine and preventive medicine at Northwestern University's Feinberg School of Medicine in Chicago.
"We don't have decades and decades of data on people who have well-controlled HIV because the idea of HIV as a chronic condition … is relatively new," he said. "We're just now starting to see some of these heart disease complications come up more commonly."
One large-scale trial, named REPRIEVE and funded by the National Institutes of Health, will examine whether statins can help prevent cardiovascular disease in people living with HIV.
"We're going to learn a lot from that study about how to predict risk," Currier said. "Do our risk calculators apply for people living with HIV, and the safety and efficacy of statins? It will definitely help us to fine-tune the information in (the statement) and could lead to actual formal recommendations or guidelines."